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Tag Archives: “Standard of Care”

What’s a lipidologist? Well, immediately we can see that the term’s Latin roots indicate that a lipidologist is someone who studies lipids. Ah, lipids: the dreaded cholesterol, et al. That seemed simple enough. A friend told me that a lipidologist practiced in Santa Fe, the only one in the whole state of New Mexico.

Okay, it’s a small state, population around 2 million, about half that of the city of Los Angeles, California. Only about 400 lipidologists work in the entire U.S. Why are they so rare? After all, blood lipids are a big deal these days. Interestingly, there is very little information in Wikipedia’s entry on Lipidology.

Despite its simple bad reputation, cholesterol is far more complicated than a mere matter of suppressing “bad” cholesterol and supporting “good” cholesterol in the bloodstream. The drug companies have worked hard to popularize the idea that cholesterol is “bad.” We produce cholesterol in the liver and we ingest it in the food we eat.

So, why do they cast cholesterol in such a bad light? Think drug company profits. I won’t get into the complex disputes over the efficacy and dangers of statin drugs in attempting to control cholesterol in the bloodstream. Or the role statins play in minimizing the risk of plaque building up in the coronary arteries. Suffice it to say, it is not all science.

Picture to the left is a Micrograph of an artery that supplies the heart showing significant atherosclerosis and marked luminal narrowing. Tissue has been stained using Masson’s trichrome. As Dr. M. explained, old plaque is scar tissue, and may not necessarily cause such blockage. High performance on a stress test indicates no blockage of cornonary arteries. Unlike new plaque, old plaque does not flake off, risking heart attack or stroke, unlike new plaque. However, both contain calcium, so measures of plaque do not distinguish between the two. So, you can have a very high score for plaque, pass the stress test indicating no blockage, and have low risk. Yet most cardiologists don’t make such distinctions; they just prescribe statins. If my arteries looked like the one in the picture here, I could not have passed the stress test with ease, as I did.

Dr. M. occupies a modest office in the local cluster of medical practices near the only hospital in Santa Fe. When I went to see him, he seemed in no hurry and spent an hour and a half with me. We had a very informative (for me) conversation about heart disease, medical practice, and the flaws of scientific practice in medicine in the U.S., where so many decisions are controlled by the insurance companies and where medical practices are dominated by the drug companies – otherwise known as “Big Pharma.”

When Dr. M. described the complex of bio-chemical, genetic, environmental, and behavioral elements that are involved with the multiple variable factors in the way cholesterol acts, I was impressed. No cardiologist had ever mentioned any of this stuff to me. It had always been a simple, “if your LDL is too high, take [the latest statin drug].” End of story.

The practice of medicine is too often a high-volume assembly-line operation that executes the “standard of care” in conformity to the specifications of Big Pharma and the medical insurance industry. Dr. M. does not play that game. He and a few other practicing medical scientists carefully measure the complex of interacting factors that may be at play in each individual and adjust treatments based on re-testing of bio-chemical and genetic factors and patient characteristics. Such doctors epitomize the scientific practice of medicine.

Medicine, it seems to me, should involve the scientific study and practice of treatments, traditional as well as modern, of potential benefit to patients. It requires carefully testing the efficacy of each treatment for a particular problem and adjusting treatment to the conditions of the individual patient. It is far more labor intensive than simple prescribing pills in accordance with the “standard of care.” I know only one lipidologist, but if he is representative of others in the specialty, then lipidology represents the best practices in medicine.

Lipidology is to the “standard of care” in cardiology as prostate oncology is to the “standard of care” among urologists, who are surgeons.

It had been a shock to be told a few years ago that I had so much plaque in my coronary arteries that I was in imminent danger of a heart attack or stroke. The cardiologist told me that I must immediately follow the protocols of the “standard of care” in cardiology and begin a course of treatment using a strong statin drug or risk the grave consequences of the failure to do so, that’s all. “Stat!” Crestor was the latest highly promoted statin, widely prescribed around the time doctors began recommending statins as “preventive” treatments for suppressing the dreaded cholesterol.

Yet, I still had questions. Why, as I mentioned previously, had I performed so well on the standard stress test? I had walked the accelerating tread-mill, climbing its increasing incline, while monitored by multiple instruments tied to me by a dozen wired sensors. I had done fine; no anomalies whatsoever. And, why had the multiple imaging methods shown no arterial blockage at all? The answer: “you’re lucky.” It was assumed that ‘so far’ the dreaded plaque was so evenly spaced that blockage had not occurred – an unlikely scenario, it seemed to me.

Now isn’t this just the typical thing a man is likely to encounter in his mid-seventies? Medical challenges abound, as do anomalous events. We don’t usually expect what we don’t want to happen.

We take our Vizsla puppy to a nearby dog park every day because she has so much energy. By nature she is a major runner and loves to play with the other dogs. Most of the dog owners there are retired too. As the dogs run and play, we sit around and chat – no, we don’t run and play, we’re not pups anymore. I’ve noticed that conversation often turns from politics to health issues. Experiences with failed diagnoses, spouse’s failing health, our own, etc., are routine. Various “alternative” health practices are a common topic of conversation. “I hate doctors,” is often heard.

But the dog park conversations were not the source of my hint of another approach to what is commonly called cardiology. Apparently, there is more to it than meets the cardiologist’s eye. One friend, a retired obstetrician, told me that he had been seeing a “lipidologist,” who had an approach to cholesterol, plaque, and heart disease in general, unlike that of the cardiologists. “I get thousands of dollars worth of advanced lab testing, and it is all covered by Medicare or is written off by the lab as part of their research.” My ears perked up. I’m always looking for some good science in medicine as an antidote to the stagnation of the “standard of care.”

Another friend who is a consummate researcher and whose wife was doing well despite having been diagnosed with stage 4 lung cancer metastasized to her brain four years before, recommended that I see the same lipidologist my other friend had mentioned. This friend had been tracking all the latest clinical trials of new experimental cancer treatments and jumping through all the hoops to get his wife into the most efficacious ones. Cancer treatment techniques are fast approaching the ability to target specific cell mutations and kill only cancer cells. If he and his wife had simply listened to the “authority” of the local oncologist and gone with the “standard of care,” (chemotherapy and radiation) I am convinced that she would have died years before she did. Even the latest treatments cannot stop some cancers. But many diseases characteristic of aging can be prevented, moderated, or delayed by wise choices, which have little to do with the “standard of care.”

About ten years after being diagnosed with a non-aggressive prostate cancer and narrowly escaping the surgeon’s knife by finding a real prostate oncologist who shared all the treatment alternatives with me, then undergoing non-invasive yet pretty darn effective treatment, something entirely unrelated happened, or so it seemed.

Self-Serving Medical Practice

I recall the urologist who had diagnosed the cancer with strong distain. He was a surgeon and had glibly said, “Don’t worry, it’s not that aggressive; give me a call and we can schedule surgery in the next couple of weeks.” His conflict of interest coincided with a complete lack of objectivity as well as indifference to the risks for the patient – me. He failed even to mention alternatives to surgery. I was lucky to find a prostate oncologist, escape the knife, and find an effective non-invasive treatment.

Then, once again, a decade after that narrow escape from unnecessary surgery, by finding the right information and dodging routine medical practice – the so-called “standard of care” – I was able to choose a better path than passive acceptance of self-serving medical “authority” would have allowed.

After a few years living in Northern New Mexico, what had been rather ordinary springtime allergies gradually morphed into full-blown year-round allergy symptoms. I was tested, and sure enough, I had become allergic to most grass and tree pollens in the area. After about four years of weekly allergy shots, my symptoms seemed moderately reduced, but far from eliminated. Then, following a particularly strong winter flu, I sustained a major sinus infection. My sinuses had become almost fully blocked. Sinus surgery followed; the result was wonderful. I was breathing clearly through my nose for the first time in years. And my allergy symptoms were reduced to occasional minor irritations.

The Arrogance of Authority

However, during the pre-op testing, EEG and EKG measures revealed a small heart valve anomaly. Of course, nobody tells you why you are getting extra tests or what the findings are. Finally, after the pre-op physician’s assistant sent me for a full abdominal ultrasound in search of a non-existent aneurysm, she scheduled me to see a cardiologist. “I don’t know why they did the ultrasound; maybe they thought you had an aneurism. But the good news is, you don’t,” said the cardiologist standing over me with a smug air of authority. He said the heart valve anomaly was minor and simply should be checked once a year. If it didn’t change, no problem.

But the cardiologist insisted that I begin taking Lipitor to keep my cholesterol numbers below their slightly elevated level. When I began to inquire about the “side effects” of statin drugs, he became indignant. “I’ve heard all those arguments. You need to take it to prevent more plaque buildup in your coronary arteries to prevent a heart attack or stroke.” He thereupon wrote a prescription for a strong dose of the generic form – Lipitor’s brand-name patent had expired. The man was over-the-top arrogant. To discuss a patient’s concern was apparently below his self-defined authoritarian dignity. I resolved to never see him again.

I was more concerned about the heart valve anomaly and didn’t like what I knew about statin drugs. So, I decided to visit the cardiologist in Beverly Hills that my oncologist had sent me to for a checkup and stress test over a decade before. He was a very bright guy, affiliated with Cedars-Sinai Hospital, and clearly part of what I would call the “high-end” medical establishment. Back then I’d had stress tests and imaging a year apart and the year of regular gym workouts with a trainer in the interim had made the initially difficult stress test easy. All clear back then.

Knowledge Overcomes “Standard of Care”

“Oh, we saw that heart-valve anomaly ten years ago; it’s nothing to worry about.” He reported that I’d done perfectly on the stress test. “But you are off the charts on your arterial plaque. You must begin strong doses of Crestor immediately.” He gave me a handful of samples, insisting that I was in serious danger, based on such a strong score on arterial plaque. I did wonder why, if it was so bad, I had performed perfectly on the stress test and the imaging showed no obstructions at all.

Well, as it turned out with further research on my part and consulting with a lipidologist, my puzzlement with the inconsistency between the stress test and the “plaque score,” was well founded. Things were not as they seemed to the high-end cardiologist. So, next time I will report, as Paul Harvey used to say, “the rest of the story.”

I keep finding myself in conversations of health and illness, as I grow older. The Mad Jubilado experiences by the very course of nature and time more health related situations and conversations than in previous stages of life. In such conversations I have noticed a certain irrationality in searches for “the solution,” where no simple (and also effective) answer can usually be found.

Along with simplicity, too many “patients” rely blindly on the “authority” of various assertions by their doctors. It is so much more comforting to find a simple solution provided by an authority figure, requiring little thought and a one-step implementation, than to pursue diverse sources of information from scientific research.

The denial of complexity is similar to denying that there is a problem. Some folks about as old as this Mad Jubilado would like to live in an age like the ideal pastoral existence they think they remember from childhood. Some things always were more complicated than we remember; many others have become even more so.

Some folks, on the other hand, revert to the no-solution solution. I remember too many conversations about which I do not remember anything else but that they contained a certain attitude of fatalism in the guise of scientific skepticism. This seems to happen less often now since most folks seem to have at least some grasp of how certain things damage people and other living things. Such conversations go something like this:

Mr. A – “Did you hear about the medical studies that show that people who eat X have a 42% greater chance of contracting colon cancer than those who don’t?”

Mr. B – “Oh, well, it seems that every day they claim that something else we eat is going to give us cancer. What are we supposed to do, stop eating? Have they really proved it? I know lots of people, for example, who smoke and don’t have cancer. It’s ridiculous; I’m not going to worry about it. We can’t control everything.”

Defeatism, Denial, and Delusion in the face of complexity: None of these is particularly useful. We do live under historically unique conditions. So many materials and chemical compounds now impinge on our lives every day that were never present in the natural environment before industrial civilization.

We have a sense that so many things just could not all be bad for us. At the same time, those who profit from our ignorance try to convince us that the pollutant their industry emits and we are concerned about is really harmless. Don’t forget, the fossil-fuel companies hired the same public relations company to promote climate-change denial that worked for the tobacco companies to convince folks that cigarettes were safe.

We live in a single-cause-of-evil culture. We want to identify the bad guy and have the Lone Ranger come and take him out. Otherwise, things should just be rosy. Just look at foreign policy; well never mind, that’s another very long story… Fact is, life can be and often is, complicated.

And so it is with our health and its relationship with the medical industry as well as the many industries that pollute our air, water, and land. One small part of the denial of the overwhelming evidence of growing climate chaos is the denial of complexity, even to the extent of imagining vast (necessarily complex) conspiracies by climate scientists all over the world to construct stories of complexity in what deniers insist is a simple world.

Recently, by not believing the standard, simple, one-culprit story of arterial plaque that dominates the thinking and practice of cardiology, I was able to dodge what I call a “standard of care” bullet. What might have induced panic about a “life threatening” condition, was resolved by turning to more data on a variety of factors and a scientific analysis of the complexities of biochemistry.

My plaque score was off the charts. Yet I passed the stress test with flying colors, demonstrating by the performance and by imaging that I had no arterial blockages. Yet the cardiologist insisted that I was in grave danger and urging that I take high doses of a new statin drug. I investigated the facts of plaque beyond the ideology of the high-end cardiologist. I consulted with a lipidologist and learned about the complexities of blood lipids and plaque, apparently beyond what the most cardiologists know.

I discovered that a high score on a narrow measure of arterial plaque was not the final word on the matter. Old plaque is essentially scar tissue, yet retains the calcium that was in the original plaque. So it results in a high score. Scar tissue does not flake off like new plaque in the artery.

Facing complexity and seeking to understand it led to a better more complete understanding of risk management and a better approach to maintaining heart health. The heart of the matter reached beyond the standard of care typical of the practice of cardiology. The same prinicple applies to many areas of risk in our complex world.